Paediatric Clinical Practice Guideline
Ankle and lower leg injuries in children
Author: Darren Baldwin / Miki Lazner / Mr S N Maripuri / Mr T Crompton Publication date: Sep 2020 Review date: Sep 2022 See also: knee injuries (microguide > paediatrics and neonatology > paediatrics > K)
Injuries covered in this guideline: Ankle sprains Ankle fractures - Lateral and medial malleolus fractures - Transitional fractures - Talar dome fractures Proximal and distal tibial and or fibular fractures (excluding injuries around the knee) Toddler fractures
Assessment
Any child with an ankle injury demonstrating neurovascular compromise must be referred immediately to the CED Consultant +/- Orthopaedic Registrar (Bleep 8629)
Ask about: - Mechanism of injury, time of injury, site of pain - After the injury: Immediate swelling? Able to weight bear? Treatments received - Neurovascular symptoms: Paraesthesia or numbness? Pallor?
All children with ankle injuries must be given adequate analgesia before careful examination from knee to toe. Use a LOOK, FEEL, MOVE approach.
Look - Observe the ankle for deformity, swelling, bruising and redness. Feel – Ask which area is the most painful and examine that last. Ask the child to point with one finger where the pain is worst. Palpate all structures from the knee down trying to pinpoint bony tenderness; Key sites: head of the fibula (proximal), tibial shaft, fibula shaft, lateral and medial malleoli, anterior and posterior aspects of the ankle and the bones of the foot, especially base of 5th metatarsal and heel. If the history warrants it, check the calf muscle (gastrocnemius) and Achilles tendon. Check for tenderness over the medial and lateral ligaments
Caution: Tenderness both laterally and medially may indicate an unstable ankle.
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Move – Test the range of movement (ROM) in the ankle joint. Is the child weight bearing? Can the child perform dorsiflexion and planter flexion, inversion and eversion movements of the ankle joint actively? Can you perform these movements passively and against resistance?
Imaging
Standard views are lateral and AP. Resist the temptation to do both foot and ankle x-rays at the same time. Decide where the injury is first. Ankle – for presumed injury to any of the bones in the ankle including talus, and calcaneal injuries. Foot – for presumed injury to base of 5th metatarsal and other bones in the foot Tibia and fibula – for presumed displaced / angulated tibia / fibula injuries and proximal injuries
Ankle injuries
Background Soft tissue injuries of the ankle are common, but in small children, the ligaments of the ankle are stronger than the growth plates to which they are attached. Thus a fracture is more likely than a ligament tear or sprain – if in doubt, especially in younger children, x-ray. This is why in CED, the ‘Ottowa ankle rules’ apply only to children ≥ 12 years.
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Teenagers can present with a special category of fracture called ‘transitional fractures’ because they are in transition from adolescence to maturity. o Often involve the articular surface - seek senior advice. Most / all ankle injuries can be managed with a walking boot – but may be weight bearing or non-bearing (NWB).
Ankle Sprains
Majority result from inversion injuries of the ankle and are often sports injuries.
Sprains are divided into three grades: Grade 1: Mild injuries – result in tearing of some ligament fibres with minimal bleeding.
Grade 2: Moderate injuries – result
in incomplete rupture of the ligament and moderate bleeding.
Grade 3: Severe injuries – characterised by complete disruption of the ligament.
Clinical Presentation
Grade 1 Grade 2 Grade 3
Pain and activity Can carry on with Pain severe Pain severe activity enough to stop enough to stop activity activity
Able to bear weight Yes Yes No
Swelling Mild Moderate Severe
Pain reproduced by stressing No laxity Some laxity Gross laxity the ligament without laxity
Loss of functional and strength No Some Possible
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Management
1. Analgesia is vital if you want the child to weight bear in the department with a grade 1 or 2 sprain.
2. If child is NOT weight bearing – x-ray ankle to check for fractures
3. If weight bearing in department: discharge home with rest (minimal walking for the first 24 / 48 hours), ice, and elevation.
- After 24-48 hours full weight bearing should be maintained with regular analgesia.
- Give patient / parent the CED ankle injuries leaflet – provides post care information and exercises.
4. If child is persistently unable or unwilling to weight bear in department (includes Grade 3 sprains), even after normal x-ray: discharge home with walking boot that is kept on 24 hours, provide crutches and arrange virtual virtual fracture clinic (may be Physio) follow up using the PANDA referral form.
5. For all children: Encourage regular analgesia Reinforce realistic expectations for recovery time • We do not expect simple ankle sprains to be pain free the day after or even the week after. • Sprains can take up to 6-8 weeks to heal properly and even then physiotherapy may be needed to maintain ankle strength. • Stress no participation in sports or high impact activities until the ankle is pain free and the patient is able to maintain normal balance on the affected ankle alone.
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Ankle and lower leg fractures
If in doubt, have a low threshold for requesting x-rays. Young children in particular can have quite subtle signs for fractures.
If unsure about x-ray findings, discuss with CED Consultant or ENP.
Ankle fracture dislocation is a neurovascular and limb threatening emergency: any child with an ankle injury demonstrating neurovascular compromise must be referred immediately to the CED Consultant +/- Orthopaedic Registrar on Bleep 8629.
Assessment
NB Provide appropriate analgesia prior to assessment: Simple analgesia such as paracetamol and ibuprofen for minimal swelling / pain. Can add oral morphine if ongoing pain not relieved with simple analgesia. Intranasal Fentanyl, intravenous morphine and Entonox for significant pain associated with deformity or significant swelling.
1. Observe the ankle for significant clinical deformity and angulation
2. Check for presence of the posterior tibial and the dorsalis pedis pulses.
3. Check sensation distal to injury
4. X-ray ankle or tibia and fibula depending on area of concern. Consider a mortise view. Remember to check talar dome for osteochondral fractures.
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Type of injury Notes Treatment Fibular injuries Proximal fibular Usually in younger children. Options: metaphyseal buckle May be associated with 1. No treatment fractures proximal tibial buckle fracture 2. Bulky bandage (e.g. (manage both bone fractures as modified Robert Jones detailed here) bandage with Softban and Easifix) All tibial metaphyseal buckle 3. If severe pain – backslab fractures need virtual fracture Can mobilise as pain allows clinic follow up due to risk of Cozen phenomenon - valgus virtual fracture clinic follow up angulation deformity of the tibia following a proximal tibial metaphyseal fracture. Late deformity. Distal fibular metaphyseal Usually in younger children. walking boot and mobilise as buckle fractures May be associated with tibial pain allows buckle fracture (manage both Backslab if not weight bearing bone fractures as detailed here) or severe pain virtual fracture clinic follow up Distal fibular greenstick or Look for tibial fracture Minimally displaced or undisplaced complete fractures Potentially unstable fractures fractures: - below knee backslab and non- weight bearing (NWB) - virtual fracture clinic follow up
Displaced fractures: Backslab and NWB refer Ortho Reg acutely Lateral malleolus Distal fibular avulsion fractures Distal fibular avulsion fractures or fractures and undisplaced type I and II undisplaced Type 1 SH fractures: Salter Harris (SH) fractures are - Treat as a sprain very low risk injuries for - If NWB – walking boot complications. - virtual fracture clinic (may be Physio) follow up
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Type of injury Notes Treatment Lateral malleolus fractures Minimally displaced or undisplaced cont. Type II SH fractures: - walking boot - virtual fracture clinic (may be Physio) follow up
Displaced Type I and II SH and all other fractures: - walking boot and NWB - refer Ortho Reg acutely Tibial injuries Proximal tibial Usually in younger children. May Options: metaphyseal buckle be associated with proximal 1. No treatment fractures fibular buckle fracture (manage 2. Bulky bandage (e.g. modified both bone fractures as detailed Robert Jones bandage with here) Softban and Easifix) 3. If severe pain – backslab All tibial metaphyseal buckle fractures need virtual fracture Can mobilise as pain allows clinic follow up due to risk of Cozen phenomenon - valgus virtual fracture clinic follow up angulation deformity of the tibia following a proximal tibial metaphyseal fracture. Late deformity Proximal tibial greenstick Look for fibular fracture Minimally displaced or undisplaced or complete fractures Potentially unstable fractures fractures: - above knee backslab and non- weight bearing (NWB) - virtual fracture clinic follow up
Displaced fractures: Backslab and NWB refer Ortho Reg acutely
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Type of injury Notes Treatment Toddler fractures (see Undisplaced fracture of DISTAL Options: separate guideline on tibial shaft with intact fibula in 1. Decision made to NOT Microguide) mobile young children, typically immobilise: < 3 years. Allow child to mobilise when comfortable Ensure regular analgesia Follow up in ED review clinic 7–10 days
2. Decision made to immobilise: toddler walking boot or long leg backslab if not available / correct size Follow up in virtual fracture clinic Distal tibia buckle fractures Usually in younger children. May walking boot and mobilise as be associated with fibular buckle pain allows fracture (manage both bone Backslab if NWB or severe pain fractures as detailed here) virtual fracture clinic follow up Distal tibia greenstick or Look for fibular fracture Minimally displaced or undisplaced complete fractures Potentially unstable fractures fractures: - below knee backslab and non- weight bearing (NWB) - virtual fracture clinic follow up
Displaced fractures: Backslab and NWB refer Ortho Reg acutely Medial malleolus fractures May be Type III SH fracture or Undisplaced fractures: occur after growth plate has - Walking boot and NWB fused. - virtual fracture clinic follow up Typically accompanied by a distal fibular fracture. Displaced fractures: - walking boot and NWB
- refer Ortho Reg acutely Look for talar shift on x-ray. Type I and II SH fractures Type I SH fractures of distal tibia Undisplaced fractures: are very rare; treat as per Type - walking boot and NWB II fractures. - virtual fracture clinic (may be Physio) follow up
Displaced fractures: - walking boot and NWB - refer Ortho Reg acutely
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Type III SH fractures Juvenile Tillaux fracture – Undisplaced and displaced juvenile transitional fracture involving the tillaux fractures: antero-lateral aspect of distal - walking boot and NWB tibia. Typically seen in 12-14 - refer to Ortho Reg acutely year olds when the distal tibial growth plate is partially fused. - Likely to require CT scanning
Growth plate fuses medially to laterally. Fracture line typically seen on AP view as vertical lucency through lateral epiphysis.
Clinical clue is anterior joint line tenderness and swelling. Type IV and V SH Involves the joint – requires Undisplaced and displaced fractures Ortho input urgently. fractures: - Walking boot and NWB - Triplane fracture – type of refer Ortho Reg acutely - Likely to require CT scanning Transitional fracture. Type IV SH fracture involving the coronal, saggital and transverse planes.
Fracture line extends from above the growth plate, along the growth plate and out into the ankle joint.
On lateral x-ray view, fracture line will be seen above the growth plate. On AP view, vertical lucency will be visible through the epiphysis.
If undisplaced, may have minimal pain. Examine carefully for anterior joint line tenderness.
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Talar dome fractures Type of osteochondral fracture. Undisplaced or displaced fractures: Occur laterally or medially. - Walking boot and NWB - refer Ortho Reg acutely Easily missed on x-ray.
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